Dressings with anesthetic and vasoconstrictor or aluminum

Med Oral Patol Oral Cir Bucal. 2013 Mar 1;18 (2):e272-8.

Hemostatic agents and apical surgery outcome

Journal section: Oral Surgery Publication Types: Research

doi:10.4317/medoral.18002 http://dx.doi.org/doi:10.4317/medoral.18002

Influence of hemostatic agents upon the outcome of periapical surgery: Dressings with anesthetic and vasoconstrictor or aluminum chloride María Peñarrocha-Diago 1, Laura Maestre-Ferrín 2, David Peñarrocha-Oltra 3, Thomas von Arx 4, Miguel Peñarrocha-Diago 5

Associate Professor of Oral Surgery. Valencia University Medical and Dental School. Valencia, Spain Master in Oral Surgery and Implantology. Valencia University Medical and Dental School. Valencia, Spain 3 Resident of the Master in Oral Surgery and Implantology. Valencia University Medical and Dental School. Valencia, Spain 4 Vice Chairman and Associate Professor. Department of Oral Surgery and Stomatology. School of Dental Medicine, University of Bern. Switzerland 5 Chairman of Oral Surgery. Director of the Master in Oral Surgery and Implantology. Valencia University Medical and Dental School. Valencia, Spain. Investigator of the IDIBELL Institute 1 2

Correspondence: Clínicas Odontológicas Gascó Oliag 1 46021 - Valencia, Spain [email protected]

Received: 10/10/2011 Accepted: 07/06/2012

MA Peñarrocha-Diago, Maestre-Ferrín L, Peñarrocha-Oltra D, von Arx T, Peñarrocha-Diago M��. �� Influence �� of hemostatic agents upon the outcome of periapical surgery: Dressings with anesthetic and vasoconstrictor or aluminum chloride. Med Oral Patol Oral Cir Bucal. 2013 Mar 1;18 (2):e272-8. http://www.medicinaoral.com/medoralfree01/v18i2/medoralv18i2p272.pdf

Article Number: 18002 http://www.medicinaoral.com/ © Medicina Oral S. L. C.I.F. B 96689336 - pISSN 1698-4447 - eISSN: 1698-6946 eMail: [email protected] Indexed in: Science Citation Index Expanded Journal Citation Reports Index Medicus, MEDLINE, PubMed Scopus, Embase and Emcare Indice Médico Español

Abstract

Objective: To evaluate the effects of different hemostatic agents upon the outcome of periapical surgery. Design: A retrospective study was made of patients subjected to periapical surgery between 2006-2009 with the ultrasound technique and using MTA as retrograde filler material. We included patients with a minimum followup of 12 months, divided into two groups according to the hemostatic agent used: A) dressings impregnated in anesthetic solution with adrenalin; or B) aluminum chloride paste (Expasyl™). Radiological controls were made after 6 and 12 months, and on the last visit. The global evolution scale proposed by von Arx and Kurt (1999) was used to establish the outcome of periapical surgery. Results: A total of 96 patients (42 males and 54 females) with a mean age of 40.7 years were included. There were 50 patients in the aluminum chloride group and 46 patients in the anesthetic solution with vasoconstrictor group. No significant differences were observed between the two groups in terms of outcome after 12 months - the success rate being 58.6% and 61.7% in the anesthetic solution with vasoconstrictor and aluminum chloride groups, respectively (p>0.05). Conclusion: The outcome after 12 months of follow-up was better in the aluminum chloride group than in the anesthetic solution with vasoconstrictor group, though the difference was not significant. Key words: Aluminum chloride, bleeding control, hemostasis, periapical surgery, outcome.

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Material and Methods

Introduction

Many factors can influence the outcome of periapical surgery. In this context, adequate bleeding control is essential for the success of periapical surgery, since it improves visualization of the surgical site, minimizes the operating time, and is a requirement for the insertion of most retrograde filling materials (1,2). Different agents and techniques have been used to secure hemostasis in periapical surgery. Bone wax has been used for many years and is easy to handle, though remaining traces of this material can cause adverse tissue reactions (3). Similar problems have been observed with ferric sulfate: when not completely eliminated from the surgical site, it gives rise to foreign body reactions that complicate healing (4). Vickers et al. (5) evaluated the hemostatic efficacy and cardiovascular effects of ferric sulfate and of cotton pellets impregnated with racemic adrenaline. Both agents afforded surgical hemostasis, and there were no significant changes in the systemic cardiovascular parameters with either of them. In a similar study, Vy et al. (6) concluded that collagen sponges impregnated with adrenaline affords excellent bleeding control, with no evident changes in either blood pressure or heart rate. Von Arx et al. (7) introduced the use of Expasyl™ (Pierre Rolland, Merignac, France) for securing hemostasis in periapical surgery. This is a paste containing aluminum chloride and kaolin, and is normally used to produce gingival retraction (8,9). In an experimental study, von Arx et al. (7) compared the hemostatic efficacy and the tissue reactions of bone wax, ferric sulfate, aluminum chloride, and a combination of aluminum chloride and ferric sulfate. Expasyl™ alone or in combination with ferric sulfate was found to be the most effective agent, and the inflammatory reactions were limited to the bone defects, with no spread to the surrounding tissues. Jensen et al. (10) used the same study design to compare the effects of 5 hemostatic techniques: Expasyl™ + Stasis®, Expasyl™ + Stasis® + bone crypt freshening with a drill, Spongostan®, Spongostan® + adrenaline, and electrocautery. The most effective methods for reducing bleeding were Expasyl™ + Stasis® and electrocautery, but adverse tissue reactions were observed (necrotic bone, inflammatory cells, absence of bone repair). Such tissue damage was not recorded when the superficial bone layer was eliminated with rotary instruments. A number of studies have been published involving different materials used to secure hemostasis in periapical surgery, though none have correlated the outcome of periapical surgery to the hemostatic agent used. The present study was carried out to compare the outcome of periapical surgery when using two different hemostatic agents: dressings impregnated with anesthetic solution containing a vasoconstrictor (adrenaline), and aluminum chloride paste (Expasyl™).

-Sample selection A retrospective study was carried out in the Oral Surgery Unit (Valencia University Medical and Dental School, Valencia, Spain) covering the period between October 2006 and March 2009 and including the patients subjected to periapical surgery with the ultrasound technique, using MTA (ProRoot®, Dentsply, USA) as retrograde filling material. The study was approved by the local Ethics Committee, and all patients gave informed consent to participation in the study. In all cases dressings impregnated in anesthetic solution with vasoconstrictor, or aluminum chloride paste, were used for securing hemostasis, and the minimum follow-up period was 12 months. Specifically, we used dressings impregnated in anesthetic solution with vasoconstrictor (4% articaine with adrenaline 1:100,000) (Inibsa, Lliça de Vall, Barcelona, Spain) in the patients treated between October 2006 and December 2007, and aluminum chloride (Expasyl™, Produits Dentaires Pierre Rolland, Merignac, France) in the patients treated between January 2008 to March 2009. In the patients with periapical lesions measuring over 20 mm in diameter, with tunnel lesions rupturing the vestibular and lingual cortical layers, or with apicomarginal defects with complete vestibular cortical loss, hemostasis was secured with dressings impregnated in anesthetic solution with vasoconstrictor, due to the difficulty of eliminating the remaining traces of Expasyl™ in such situations. In these cases we always used bone regeneration techniques, and decided to exclude the patients from the study, since they all belonged to the adrenalin with vasoconstrictor group. We likewise excluded those patients in which no hemostasis material had been used (9 patients). The resulting initial study sample consisted of 123 patients, divided into two groups according to the hemostatic agent used: A) dressings impregnated in anesthetic solution with adrenalin (55 patients); or B) aluminum chloride paste (Expasyl™)(68 patients). Eight patients were excluded due to incomplete study protocols (one in the dressings group and 7 in the Expasyl™ group), 14 because of a lack of follow-up (3 in the dressings group and 11 in the Expasyl™ group), and 5 patients in the dressings group in which bone regeneration techniques had been used (3 patients with periapical lesions measuring over 20 mm in diameter, one with a periapical lesion rupturing the vestibular and lingual cortical layers, and one patient with an apicomarginal defect and complete vestibular cortical loss). The final study sample thus consisted of 96 patients: 46 belonging to the dressings with anesthetic and vasoconstrictor group and 50 to the Expasyl™ group. -Surgical technique All the operations were made by the same surgeon e273



(MPD). Locoregional and infiltrating anesthetic techniques were used with 4% articaine and adrenaline 1:100,000 (Inibsa, Lliça de Vall, Barcelona, Spain). Intrasulcular incisions were made with one or two vertical releasing incisions for raising triangular or trapezoidal mucoperiosteal flaps. Ostectomy was performed using a rounded 0.27 mm tungsten carbide drill (Jota, Switzerland) under abundant irrigation with saline solution. The minimum apical resection needed to access the apexes was made, followed by apical curettage. The cavity was prepared for retrograde filling using a Piezon Master® 400 ultrasound instrument (EMS, Electro Medical Systems, S.A., Switzerland) at full power with diamondsurfaced ultrasound tips for periapical surgery. To facilitate the procedure, use was made of a Medi Pack Pal endoscope (Farol Store and Co., Tuttlingen, Germany) and Moeller® Dental 300 surgical microscope (MöllerWedel International, Bedel, Germany). Bone cavity drying and bleeding control was carried out in group A by means of small sterile dressings impregnated with anesthetic solution with adrenaline as vasoconstrictor at a concentration of 1:100,000 (Inibsa, Lliça de Vall, Barcelona, Spain), placed within the bone crypt. Dry dressings were then placed and pressure was applied for two minutes, after which all the dressings except the first impregnated dressing were removed, and the surgical procedure was continued – removing the impregnated dressing before saline irrigation and suturing (Fig. 1). In group B use was made of ExpasylTM (Expasyl,

Produits Dentaires Pierre Rolland, Merignac, France) applied during two minutes (Fig. 2). Finally, ProRoot® (Dentsply, USA) mineral trioxide aggregate (MTA) retrograde filling material was prepared, inserted and condensed, following the indications of the manufacturer. In the patients in which Expasyl™ was used, the bone crypt was refreshed with a rounded drill under abundant irrigation before suturing. Suturing was carried out with Tevdek® non-reabsorbable sutures (Deknatel®, Teleflex®, Athlone, Ireland) composed of polyester fibers coated with polytetrafluoroethylene (PTFE). In all cases the following medication was prescribed in the week after surgery: amoxicillin 500 mg with clavulanic acid 125 mg every 8 hours during 6 days; ibuprofen 600 mg every 8 hours during 4 days; 0.12% chlorhexidine gluconate rinses three times a day during 7 days; and paracetamol 500 mg upon demand in the event of important pain. -Radiographic evaluation Periapical and panoramic X-rays were obtained with an XMIND® intraoral system (Groupe Satelec - Pierre Rolland®, France), together with digital panoramic X-rays (OP100®, Instrumentarium Imaging, Tuusula, Finland). Radiographic controls were made immediately after surgery, after 6 and 12 months, and on occasion of the subsequent annual control visits. The months elapsed from surgery to final control (counting to the last visit of each patient) or until failure were recorded for calculating mean patient follow-up.

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Fig. 1. Periapical surgery of an upper second premolar using dressings impregnated with anesthetic and vasoconstrictor as hemostatic agent. A) Preoperative clinical view. B) Periapical X-ray view showing a periapical radiotransparent area in relation to the apex of the second premolar. C) Intraoperative view following ostectomy. D) View of the bone cavity after curettage of the periapical lesion. E) Hemostasis with dressing impregnated with anesthetic and vasoconstrictor. F) Retrograde filling with MTA. G) View of retrograde filling after eliminating the excess MTA and impregnated dressing. H) Radiological control after 12 months of follow-up.

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Fig. 2. Upper left premolars periapical surgery using Expasyl™ to control bleeding. A) Preoperative clinical view. B) Periapical X-ray view showing a periapical radiotransparent area between the apexes of both premolars. C) Periapical lesion after ostectomy. D) View of the bone cavity after curettage of the periapical lesion. E) Expasyl™ inserted in the bone crypt and allowed to act during two minutes. F) The cavity is irrigated with sterile saline solution to remove the excess Expasyl™. G) Retrograde cavities prepared in both teeth. H) Retrograde filling with MTA. I) Periapical radiological control after 12 months of follow-up.

Results

-Scales of success The outcome of periapical surgery was assessed based on the global evolution scale proposed by von Arx and Kurt (11), which combines clinical and radiological criteria. Outcome was classified as: 1) success: when bone regeneration was ≥ 90% and the clinical and pain score was 0 (on a scale of 0-3); 2) improvement: when bone regeneration was 50-90% and the clinical and pain score was 0; and 3) failure: when bone regeneration was < 50% or there were clinical symptoms. -Data collection and statistical analysis A clinical history was compiled for all patients, following a previously established protocol - recording the personal antecedents of interest, collecting all the clinical and radiographic data of the patients in detail, and registering the pre-, intra- and postoperative characteristics. The SSPS version 15 statistical package for MS Windows was used for analyzing the data. In each study group we performed a descriptive analysis of all the variables (gender, age and area of the periapical lesions), checking that there were no differences between the two groups for any of these variables. The outcomes of periapical surgery after 6 and 12 months and at the final control, in each group, were compared using the chi-squared test, with a statistical significance level of p